Laserfiche WebLink
APPLICATION FOR PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> t (Complete in Triplicate) <br />} Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.`` } <br /> Job Address /p � t J City f 11 <br /> /`-?' L Lot Size pM <br /> Owner's Name �vsC Cli C Address ±o. <br /> Phone <br /> Contractor " AddressLicense Phone <br /> TYPE OF WELL/PUMP: NEW WELL C1 . WELL REPLACEMENT ❑ DESTRUCTION Q <br /> PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP, LINE ` <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Dia. of Wel! Casing <br /> " f'1 Public5pecificatians \' <br /> f t Other 171 Delta Depth of Grout Seal <br /> I 1 Irridtion Type of Grout _ { <br /> J' _ -Approx. Depth I i Eastern Surface Seal,installed by <br /> Repair Work Done . ❑ Type of Pump H.P. - <br /> State Work pone_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth 1 Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION i I DESTRUCTION <br /> (No septic system permitted if public sewer is 4 <br /> available within 200 feet.) Q <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3'feet: <br /> ` -SEPTIC TANK- - Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Q ' <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line 1 <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED © Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS I I Depth I Size <br /> - Number <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> employ any person in such manner as to bec <br /> Home owner or licensed agent's signature certifies the following, "I certify that in the performance of the work for which this permit is issued, I shall not i <br /> ome subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the-performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa-.., <br /> tion laws of California." <br /> The applicanty m i call for all re ired inspections. Complete drawing on reverse side. <br /> Signed X <br /> - Y Title: Data: X", <br /> fk <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date��� Area. <br /> Pit or Grout inspection by Date Final Inspection by <br /> D <br /> 3 <br /> ate <br /> Additional Comments: <br /> ❑.Stk 466.6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> f� <br /> INFO CASH RECEIVED BY DATE PERMIT N0. <br /> + EH 14-24)REV. �� ^1 r ' <br /> EH 14-29Li7/�[) h� <br /> OJ* � <br />